patient election to self-pay for services

Certus Psychiatry and Integrated Care ("Clinic") is a participating provider with the aforementioned ("Company").

I, the undersigned patient, acknowledge that I understand and agree that:

1. I am covered by one of the Company Health insurance Plans.


2. The health plan under which I am covered includes benefits for some or all of the services provided by Clinic.


3. Despite the above, I do not wish Clinic to submit a claim to Company for services provided to me by Clinic.


4. Until such time as I may otherwise advise Clinic in writing, I elect to pay for all services I receive from Clinic at their Certus Psychiatry discounted rates.


5. By electing to self-pay for services, any payments I make to Clinic will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with Company unless otherwise permitted under the terms of my health plan.


6. I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form. Any questions I may have had about this form have been answered to my satisfaction.


7. I have freely chosen to self-pay for services after having asked Clinic about payment options and having carefully considered those options.